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    Secure Credit Application Form
 

Business Name    

 

Type of Business    

 
Address     
City     
Zip Code      
Federal tax ID or Social    
Security Number    		  
Date Business Established       / /
Number of Employees      
Phone       
email       

 Purchasing Contact Person    
Phone   
Fax    
    
    

 Accounts Payable Contact Person    
Phone     
Fax     
   

  

     Corporation  
    Partnership   
    Sole Propreitorship

Business is a:   

 

Tax exempt?      

     Yes  No 

State of Incorporation      

Names, titles, and addresses    
 of three chief corporate     
officers  (or partners)      
Name 
 Title  
Address 
Name 
 Title  
Address 
Name 
 Title  
Address 

Type of products you    
  intend to purchase    

  


Names of authorized    
 purchasers    

 1.
2.
3.

Purchase order required?     

      Yes  No   
    

 Trade References

1
Name   
Address
City    
Zip code 
Phone

2
Name
Address 
City
Zip Code
Phone

3
Name  
Address  
City 
Zip Code
Phone
   
Bank Reference
Account #  
Contact Person
Name of Bank 
Phone 
    
 Agreement
I represent that the above information is true and is given to induce  to extend credit to the applicant. My company and I authorize  to make such credit investigation as  sees fit, including contacting the above trade references and banks and obtaining credit reports. My company and I authorize all trade references, banks, and credit reporting agencies to disclose to  any and all information concerning the financial and credit history of my company and myself.
I have read the terms and conditions stated below and agree to all of these terms and conditions.
Name:
Title:
Date:  / /